Findings on Supported Employment in Rural Areas:

There is limited research specifically related to the delivery of supported employment in rural areas.  However, the existing literature shows there is little empirical evidence that there are definitive differences between rural and urban supported employment participants, programs, funding or best practice (Rural Institute, Rural Facts).  In fact, some of the studies show that supported employment outcomes are slightly better in rural areas (Drake, et al, 1998 and Becker, et al, 2006).  The following gives a brief synopsis of studies that relate to supported employment practice in rural areas.

One study looked at regional variation in competitive employment for persons with SMI.  (Drake, et. al., 1998).  This study found:

Another study looked at factors that affect client access to SE services and efficiency i.e. percentage of people working of those receiving SE services (Becker, et. al., 2006).  The study included 26 evidence-based supported employment programs from seven states.  One of the variables examined included population density.  Findings in this study included:

Meisler & Williams (1998) described the implementation of supported employment evidence-based practice in a rural community in South Carolina.  Although there were obstacles encountered with recruiting, training and retaining qualified staff, 60% of program enrollees held at least one job after they entered the program and employment outcomes fluctuated between 25% and 40% over a two year period.

Clarifying Some of the Misconceptions:

Myth #1

Supported employment specialists can only provide employment services and have to be full-time employment specialists to meet good fidelity.  Rural programs cannot afford to do this.

True, outcomes are better if the employment specialists can be full-time and provide only vocational services.  However, this is only one of 25 items on the fidelity scale.  It is possible, and there are programs that have met good fidelity (rating high on service and organizational items), but also either have an employment specialist working part-time or doing some case management functions.  This is not ideal and outcomes will not be as high, but it is possible.  Typically, when implementing the supported employment evidence-based practice, the program is asked to work toward increasing the time the employment specialist does employment work while decreasing their other duties.  As referrals increase, many programs have been able to do this successfully.

Myth #2

Rural communities have fewer employment options, and therefore, cannot be successful in realizing high competitive employment outcomes.

Studies have been mixed in terms of the labor market’s effect on the hiring of people with psychiatric disabilities.  This does not mean that implementation of supported employment cannot be successful.  Even when the labor market affects outcomes, it has been found that supported employment services continue to deliver better outcomes. 

One study looked at the heterogeneity and effectiveness of SE-EBP and the effect of local welfare systems and labor markets.  It found that SE-EBP was effective in widely differing labor markets and welfare contexts (Burns, et. al, 2007)

Myth #3

The stigma of having a mental illness is high in rural areas – everyone knows everyone – and no one will hire our clients.

One rural program in Kansas that started implementing supported employment in 2004 lamented the difficulties of helping consumers gain employment in a small, rural county with a population of 22,203.  This program had 24% of the consumers in their program working at the beginning of implementation.  Two of the main concerns were: 1) that most consumers did not want to work; and 2) the stigma that existed in the business community.  At the onset of implementation, two primary strategies were used.  The first was to educate staff and consumers on the benefits of work and how work affects benefits.  The second strategy implemented was job development.  The employment specialist focused a significant amount of time learning how to develop relationships with businesses and assist them in making hiring decisions based on good job matches.  In one year, the competitive employment outcomes of that program went from 24% to 63%

Implementation in rural Kansas:

Current implementation sites

In Kansas, most sites are rural or have significant rural regions in their catchment areas.  Of the sixteen mental health centers currently implementing evidence-based practice supported employment in Kansas, seven (44%) are serving rural catchment areas.  Of those serving rural areas, one program has started implementing the practice within the past six months.  83% of the rural programs who have been implementing the practice for over one year have achieved good fidelity.  Employment outcomes for those rural programs who have achieved good fidelity range from27% to 50% with an average of 35% across programs.

Experience from Courtesy fidelity reviews

In 2006, courtesy fidelity reviews were provided for those centers who wanted to see where their supported employment program rated on the fidelity scale.  Of those mental health centers that are currently not implementing and are rural/frontier centers, four mental health center supported employment programs participated in courtesy fidelity reviews.  One of those centers had two SE programs that were reviewed separately.

The data from these centers was examined to see if there were certain elements of the fidelity scale common to rural/frontier centers where low scores consistently occurred.  Of the four centers (one center had two separate program ratings for two locations), four programs scored in the fair supported employment implementation range and only one was scored “not supported employment”.

It was assumed that if the majority of these programs scored low in a fidelity item, there would be perhaps a barrier unique to rural areas for that particular fidelity element.  Four fidelity items were found to be consistently rated low in the rural programs, however only two of the items were specific to the rural nature of the program (staff providing vocational services and employment specialists’ function as a unit). 

1.      Staff provide only vocational services:  It is difficult for many rural areas to have staff that dedicate 100% of their time to vocational services.  Typically, employment services staff in rural areas have multiple jobs (e.g. housing specialist, case manager, etc.). 

2.      Employment specialists function as a vocational Unit:  this item indicates that there should be more than one employment specialist that function as a unit and meet weekly.  There is a barrier for rural centers on this item because generally smaller, rural centers have one FTE or less which does not allow for a vocational unit. 

3.      Zero Exclusion:  this item indicates that there should be no eligibility requirements for the program other than the client wants to work.  Four out of the five programs rated 3 or below on this item.  The remaining program scored a 5.   This item is largely an attitudinal and philosophic one – understanding that “job readiness” does not predict employment success.  The lower ratings in this fidelity item related to informal screening out by case managers and diverting clients who wanted to work to prevocational programs.  This is less related to the program being rural and more to do with the organizational culture.  Many urban programs initially rate low in this area before concentrating on promoting an organizational culture that supports clients working.

4.      Time in Community: this item indicates that the majority of the employment specialists’ time should be in the community.  Three out of the five programs rated a “2” in this area.  Two of the programs rated 4/5.  This item is also less related to the program being rural.  Many urban programs also have difficulty with obtaining a high score in this area.

Challenges and Facilitators in Rural Areas

Challenges:

Although SE-EBP can be implemented successfully in rural areas, there are specific challenges to be met.  In smaller, rural programs, there are not enough referrals or new people to work with that allows Vocational Rehabilitation (VR) funding to support the program.  Some of the rural/frontier agencies are not using VR funding and some will not use Medicaid funding. A second challenge is finding ways for consumers to get to jobs when they do not have a car in rural communities.  Thirdly, in smaller towns, there are fewer job options available to consumers which can impede attainting employment and the ability to match jobs to consumer preferences.

Strategies for Overcoming Challenges:

1.      Funding

As it can be difficult for smaller programs to use VR to fully support services, using multiple funding steams appears to be the most effective strategy.  Using a combination of VR funding as well as Medicaid has assisted programs in sustaining services.  The recent change to the Ticket to Work (TTW) Program also delivers the possibility of a new revenue source.

2.      Job Development

Effective job development is the key to impacting the hiring of consumers.  Employment specialists must develop relationships with the business community and be active participants within the business community.  Some additional creative job development strategies that have been successful in rural areas include (Griffin, Hammis & Geary, 2007):

3.      Micro-Enterprise and Small Business Development 

This is assisting consumers to fill gaps in the community consistent with their desires and abilities by starting their own small business.

4.      Transportation

Montana has found transportation vouchers effective.  Other rural communities have used co-worker car pools, using Social Security Work Incentive such as PASS Plans to underwrite transportation costs, and matching people to jobs of choice within walking distances of their homes. (The Rural Institute: Rural Facts/Rural Supported Employment)

5.      Use of PASS Plans

PASS Plans have been used for a multitude of things including underwriting community-based training; pay for self-employment start-up, expansion or improvement; pay for transportation; pay for additional education or training.

Sources:

Becker, D.R., Xie, H., McHugo, G.J., Halliday, J., and Marinez, R. A.  (2006) What
     Predicts Supported Employment Outcomes?  Community Mental Health  
     Journal, 42:3, 303- 313.

Burns, T., Catty, J. Becker, T. Drake, RE, Fioritti, A., et. al. (2007). The
     effectiveness of supported employment for people with severe mental illness:
     a randomized controlled trial.  The Lancet, V. 370, September 2007.  P. 1146-
     1152.

Drake, R. E., Fox, T.S., Leather, P.K., Becker, D.R., Musumeci, J.S., Ingram, W.F.,
     and McHugo, G.J. (1998)  Regional variation in competitive employment for
     people with severe mental illness.  Administration and Policy in Mental Health,
     25(5): 493-504.

Griffin, Cary, Rural Routes: Promising Supported Employment Practices in America’s Frontier. 
      http://www.worksupport.com/documents/article12.pdf

Griffin, C., Hammis, D., and Geary, T.  (2007)  The Job Developer’s Handbook:
     Practical Tactics for Customized Employment.  Paul H. Brookes Publishing
     Company: Baltimore, Maryland.

Meisler, N. and Williams, O. (1998) Replicating effective supported employment
     models for adults with serious mental illness.  Psychiatric Services, 49(11):1419-
     1421. The Rural Institute: The University of Montana, Missoula, MT: 
     Publications: www.ruralinstitute.umt.edu

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